of Aboriginal and Torres Strait Islander children aged 0–14 had seen a dentist in the last 12 months in 2018–19
of Indigenous Australians aged 15 and over were reported to have complete tooth loss and 45% had lost at least one tooth, in 2018–19
Indigenous children aged 0–4 were hospitalised for dental conditions at 1.7 times the rate of non-Indigenous children) between July 2015 and June 2017
Why is it important?
Oral health refers to the health of tissues of the mouth: muscle, bone, teeth and gums. The two most frequently occurring oral diseases are tooth decay (termed ‘caries’) and gum (periodontal) disease. If not treated in a timely manner, these can cause discomfort and tooth loss, impacting a person's ability to eat, speak, and socialise without discomfort or embarrassment (Williams et al. 2011). Oral diseases can intensify other chronic diseases (Jamieson et al. 2010a) and have been found to be associated with cardiovascular diseases (Ylöstalo et al. 2006), diabetes (Taylor & Borgnakke 2008), stroke (Joshipura et al. 2003) and pre-term low birthweight (Roberts-Thomson et al. 2008; Williams et al. 2011; Xiong et al. 2006).
Aboriginal and Torres Strait Islander children and adults have much higher rates of dental disease than their non-Indigenous counterparts across Australia, which can be largely attributed to the social determinants of health, such as poverty, racism and the consequences of colonialism (Australian Medical Association 2019). Indigenous Australians are more likely than non-Indigenous Australians to have multiple caries, have lost all their teeth, and/or to have gum disease (Jamieson et al. 2010b) and also less likely to receive the dental care that they need (Jamieson et al. 2010a; Kruger & Tennant 2015; Slade et al. 2007).
Tooth decay can be largely prevented by diet (for example reducing intake of processed sugary foods/drinks), fluoridation of water supplies (Lalloo et al. 2015), appropriate use of fluoridated toothpaste, good oral hygiene and regular dental check-ups. The same risk factors apply to periodontal diseases as well as smoking, diabetes, stress, and substance use (particularly inhalant use). Lower levels of education and income and sub-standard living conditions are associated with oral diseases (Lalloo et al. 2016). In addition to oral hygiene and dental care, tooth loss is associated with increased age and accidents and injuries (Jamieson et al. 2010a; Williams et al. 2011).
Burden of disease
In 2011, oral disorders accounted for 1.7% of the total burden of disease among Indigenous Australians. The oral disorders contributing to this burden were dental caries (68%), periodontal disease (17%), severe tooth loss (15%) and other oral disorders (0.2%). The burden due to dental caries was most common among children, periodontal disease was most common among those aged 40–64 and severe tooth loss was most common among those aged 55–64 (AIHW 2016).
What does the data tell us?
Self-reported survey data
Through the 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey), 81% of Indigenous Australians reported that they brushed their teeth daily and 45% brushed their teeth twice a day. An estimated 50% of Indigenous Australians had seen a dentist in the last 12 months and 12% had never seen a health professional about teeth.
Of Indigenous Australians who had seen a dentist, 38% visited private dentists, 28% a government dental clinic, 12% a school dentist, and 18% a dentist at an Aboriginal Medical Service. Around half (49%) of Indigenous Australians living in Non-remote areas waited less than one week to see a dentist (Table D1.11.11).
An estimated 19% of Indigenous Australians reported that they didn’t go to a dentist when they needed to in the previous 12 months. Reasons included: cost (42%), too busy (24%), disliking service or professional, or feeling embarrassed or afraid (22%) and waiting time too long or not available at time required (15%) (Table D3.08.3, Figure 1.11.1).
Figure 1.11.1: Indigenous Australians who needed to go to a dentist in the last 12 months but didn't, by reason, 2018–19
Of Indigenous children aged 0–14 who had seen a dentist, 30% attended a school dental clinic, 28% attended a private clinic (including specialists), 24% attended a government dental clinic and 14% attended a dentist at an Aboriginal Medical Service. Of Indigenous children living in Remote areas, 38% went to a school dental clinic, compared with 28% of those in Non-remote areas (Table D1.11.29, Figure 1.11.2).
In 2018–19, 3% of Indigenous children aged 0–14 were reported as needing to go to the dentist in the past 12 months but did not. The most common reasons parents attributed this to were: cost (32%); disliked service or professional or felt embarrassed or afraid (17%); too busy (16%); or waiting time or an appointment not available at the time required (13%) (Table D3.08.3).
Figure 1.11.2: Type of dental practice attended by Indigenous children 0–14, by remoteness, 2018–19
Based on self-reported data from the 2014–15 National Aboriginal and Torres Strait Islander Social Survey, 28% of Indigenous children aged under 15 had teeth or gum problems in 2014–15 (Table D1.11.1). The most common types of problems were cavities or dental decay (12%), fillings due to dental decay (11%), needing braces/plate/retainer (6%) and having teeth pulled out due to dental decay (5%) (Table D1.11.3, Figure 1.11.3).
Among Indigenous children with reported teeth or gum problems, 56% experienced the problem for at least 12 months. This was more common for Indigenous children living in Non-remote areas (58%) compared with Remote areas (45%) (Table D1.11.5). Just over 29% of Indigenous children had their last dental check less than 3 months ago, and 8% with reported teeth or gum problems had never been to a dentist (Table D1.11.6).
The largest proportion of Indigenous children with teeth or gum problems was for those aged 10–14 (39%), followed by those aged 5–9 (33%) and 0–4 (11%) (Table D1.11.4).
Figure 1.11.3: Proportion of Indigenous children aged 0–14 with reported teeth or gum problems, by type of dental or gum problem, 2014–15
Child Dental Benefits Schedule
In 2015, 45,396 Indigenous children received dental services under the Child Dental Benefits Schedule, representing 20% of those eligible for these services. In comparison, 35% of eligible non-Indigenous children had received these services (Table D1.11.26).
Dental health in the Northern Territory
Between August 2007 and December 2018, 37,005 dental services were provided to 13,786 Indigenous children under the National Partnership Agreement on Northern Territory Remote Aboriginal Investment (NTRAI). Over this period, 86% of Indigenous children who had a dental service had two or more dental checks (Table D1.11.22). Over half (51%) of Indigenous children who received a dental service were aged 6–11 (Table D1.11.23).
Between August 2007 and June 2012, 7,403 Indigenous children received dental services under the Child Health Check Initiative Program and 46% of those children were treated for at least one dental problem. Thirty-eight per cent of Indigenous children who received dental services under the program were treated for untreated tooth decay (Table D1.11.25).
The Stronger Futures in the Northern Territory (SFNT) program began in July 2012 and continues to provide funding through the NTRAI from 2015–16 to 2021–22. The oral health component of this agreement replaced and expanded services implemented under the Northern Territory Emergency Response Child Health Check Initiative and the Closing the Gap in the Northern Territory National Partnership Agreement. The funding was mainly used to enhance oral health services to children aged under 16 in the Northern Territory.
Between July 2012 and December 2018, 13,143 children received 25,419 clinical services. The numbers fluctuated over time but were lower in 2018 than in 2016 or 2017. The proportion of dental service recipients with tooth decay decreased for most age groups between March 2009 and December 2018. The largest decrease was for Indigenous children aged 1–3 combined (from 73% to 41%), followed by those aged 12 years (from 81% to 63%) (AIHW 2019).
The 2018–19 Health Survey collected data on tooth loss. This data showed that 6% of Indigenous Australians aged 15 and over were reported to have complete tooth loss, and a further 45% having lost at least one tooth (excluding wisdom teeth) (Table D1.11.7, Figure 1.11.4).
Figure 1.11.4: Status of tooth loss, Indigenous persons 15 years and over, by age, 2018–19
In 2018–19, rates of complete tooth loss were highest for Indigenous Australians aged 55 and over living in Non-remote areas (26%). This compared to 22% of Indigenous Australians aged 55 and over living in Remote areas (Table D1.11.10).
The proportion of Indigenous Australians with complete tooth loss was higher for those with: three or more long term health conditions (8.6 times those with no conditions); Year 9 or below as the highest year of schooling (8 times those with Year 12); the lowest income (4.9 times those with the highest income); heart or circulatory problems (4.9 times those without heart/circulatory problems); and self-reported diabetes or high blood sugar levels (4 times those without diabetes or HSL) (Table D1.11.8, Table D1.11.9).
Between July 2015 and June 2017, Indigenous children aged 0–4 were hospitalised for dental conditions at 1.7 times the rate of non-Indigenous children (6.2 and 3.7 per 1,000, respectively) and those aged 5–14 were hospitalised at 1.3 times the rate (6.1 and 4.6 per 1,000, respectively). Hospitalisation rates of Indigenous Australians for dental problems declined after age 14 (Table D1.11.21, Figure 1.11.5).
Figure 1.11.5: Age-specific hospitalisation rates for a principal diagnosis of dental problems, by Indigenous status and age, Australia, July 2015 to June 2017
Data on hospital dental procedures involving general anaesthesia show that the highest rates were for Indigenous children aged 5–9 (12 per 1,000) followed by those aged 0–4 (8 per 1,000). For those aged 10 and over, rates of hospitalisation for dental procedures involving general anaesthesia were lower for Indigenous Australians than non-Indigenous Australians (Table D1.11.28).
Indigenous Australians aged 25–34 (1.7 per 1,000) were 3.5 times as likely to be hospitalised for periodontal disease compared with non-Indigenous Australians (0.5 per 1,000) (Table D1.11.31).
Child Dental Health Survey
In the 2010 Child Dental Health Survey, the average number of decayed, missing or filled deciduous teeth (baby teeth) among Indigenous children aged 5–10 was 1.7 times the number for non-Indigenous children (3.8 and 2.2, respectively) in the six jurisdictions combined with data of adequate quality (Queensland, Western Australia, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory) (Table D1.11.13). Indigenous children aged 5–10 were less likely to have no decayed, missing or filled deciduous teeth (24%) than non-Indigenous children (45%) (Table D1.11.14, Figure 1.11.6).
Figure 1.11.6: Proportion of children aged 5–10 with no decayed, missing or filled deciduous teeth (dmft = 0), by age and Indigenous status, 2010
By age 14–15, Indigenous children had on average, twice as many decayed teeth, 2.8 times the number of missing teeth and 1.4 times the number of filled teeth than non-Indigenous children (Table D1.11.15). For those aged 6–15, 48% of Indigenous children had no decayed, missing or filled permanent teeth compared with 63% of non-Indigenous children (Table D1.11.16, Figure 1.11.7).
Figure 1.11.7: Proportion of children aged 6–15 with no decayed, missing or filled permanent teeth (DMFT = 0), by age and Indigenous status, 2010
What do research and evaluations tell us?
Poor oral health is strongly associated with low socioeconomic status. Research has shown that adults who are socially disadvantaged or on a low income have more than double the rate of poor oral health than those on higher incomes, including higher rates of untreated decay (Brennan et al. 2019).
Western dental approaches (for example fluoride varnish), while clinically efficacious may not be enough to lead to lasting dental improvement in Indigenous Australian children, where other determinants such as socioeconomic status, access to services, and cultural and environmental factors act as barriers to oral health (Patel et al. 2017; Smith et al. 2007; Williams et al. 2011). Community-based interventions for oral health care should build on community strengths and harness local Indigenous Health Workers to work with families and communities in oral health promotion (Slade et al. 2011).
An effective program in Port Augusta, South Australia, highlighted the challenges in achieving this mix of community engagement, health promotion and provision of dental services. The program also faced a number of hurdles with patient attendance, including difficulties with transport, and a lack of understanding of the importance of dental health among Indigenous Australian families (Parker et al. 2012).
In South Australia, the Aboriginal Health Program introduced in 2005 saw an increase of Indigenous Australians accessing mainstream dental care from 60 to 4,800 people by 2014–15. The key strategies of the program include: ensuring Indigenous adults are referred to dental services for free general and emergency dental care with no waiting lists; increasing the number of Indigenous teenagers accessing dental care; ensuring Indigenous children can access dental care from a variety of pathways; working with health professionals and pregnant women to increase their oral health knowledge; and to develop a range of oral health resources for Indigenous Australians (The University of Adelaide 2020).
Development and implementation of evidence based oral health promotion and prevention programs is fundamental to effective provision of appropriate services to meet population oral health needs. Improving the evidence base for oral health promotion programs for Indigenous Australians is necessary (COAG Health Council 2015).
Patel and others (2017) published a review of oral health interventions for Indigenous Australian communities (Patel et al. 2017). The review found oral health interventions should not just be community-based but also community-driven with a shared understanding of outcomes, and mutually reinforcing and coordinated activities including using the skills of local staff and building capacity in oral health promotion. However, the impact of social determinants beyond the delivery of oral health services will continue to limit the effect of oral health interventions on Indigenous health outcomes, and contribute to the disparity between Indigenous and non-Indigenous Australians.
Gwyn and others (2020) published a review of international studies and evaluations of community based oral health interventions targeting indigenous adolescents and found a shortage of good quality evaluations (Gwynn et al. 2020). Studies lacked strong indigenous community engagement, governance or leadership. The review recommended that this must be included in community based oral health interventions and research.
Available data indicate that dental health is worse for Indigenous Australians than for non-Indigenous Australians, for both children and adults. Barriers to good oral health include cost of services (see measure 3.14 Access to services compared with need) and healthy diets on limited budgets (see measure 2.19 Dietary behaviours). Further barriers include attending services for pain not prevention, insufficient education about oral health and preventing disease, public dental services not meeting demand, lack of fluoridation in some water supplies, and cultural competency issues with some service providers (see measure 3.08 Cultural competency) (Durey et al. 2016; Dyson et al. 2014; Johnson et al. 2014).
Dental health workforce shortages in remote areas need to be addressed with creative solutions beyond financial incentives to improve workforce retention. Stronger representation of Indigenous Australians in the dental health workforce will likely be highly valued by Indigenous patients, and improve the cultural safety of services and hospitals. Regulatory hurdles that affect some dental services (such as fluoride varnish) need to be overcome to improve the flexibility and delivery of effective dental care (Australian Medical Association 2019).
The data also illustrates the importance of school dental programs for many Indigenous Australian children, particularly those living in remote areas. Schools are common settings for oral health interventions internationally as an opportunity for targeting student dental needs. However, they may be underutilised by Indigenous Australian children (Parker et al. 2012). This could mean mainstream school dental services lack cultural safety, but may be filling a service gap in the absence of a more suitable alternative, such as a culturally friendly children’s dental service incorporated into an Aboriginal Community Controlled Health Service.
School-based interventions may crowd out opportunities to deliver oral health promotion to families. Evidence suggests there is a lack of community understanding about the importance of oral health. This understanding could be built through community-driven programs working with dental care providers and with mutually reinforcing and coordinated activities that involve families. However, barriers to sustainable oral health improvements will remain until the broader social determinants and inequities affecting Indigenous Australians are addressed.
Prevalence estimates for oral health conditions for Indigenous Australians are based on incomplete or out-of-date surveys—further data development is a priority for this performance measure.
A more coordinated and consistent approach to research and evaluation will provide the basis for continuous improvement of oral health services and systems.
The policy context is at Policies and strategies.
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